Opioid Use Linked to Increased HCV

Rising hepatitis C and opioid use ran parallel in four states.

Action Points

Note that this population-based study found a sharp rise in new cases of HCV infection in four states.

Be aware that, although causality can not be confirmed, IV opioid abuse has increased in those states in tandem with increased HCV rates.

The incidence of hepatitis C virus (HCV) jumped nearly fourfold among people 30 or younger over a 7-year period in four central Appalachian states, the CDC is reporting.

The rise was paralleled by increasing treatment admissions for opioid dependency with significantly more patients reporting injection drug use, according to an analysis in the May 8 issue of Morbidity and Mortality Weekly Report.

Surveillance data suggested that people 30 or younger living in non-urban areas accounted for the majority of cases, with some 73% of those citing injection drug use as a risk factor.

The most efficient way of transmitting HCV is through contaminated blood, and in the U.S. injection drug use is the primary risk factor for infection.

To help understand the phenomenon, researchers from the CDC and the health departments of Kentucky, Tennessee, Virginia, and West Virginia analyzed surveillance data for acute HCV cases as well as information about drug treatment admissions.

All told, the analysis showed, there were some 1,377 cases of acute HCV infection reported to CDC from the four states over the 7-year period, with about 45% ages 30 or younger.

The median age was 25, and cases were almost evenly split between men and women.

In that age group, analysis showed, the incidence of new HCV cases was about 1.5 per 100,000 population in 2006 but had grown to about 5.5 cases per 100,000 by 2012.

Over the study period, the number of new cases rose by a factor of 3.64, the report said.

In each year, the investigators found, the rate of new cases in non-urban counties -- defined as those with fewer than 50,000 people -- was more than double the rate in urban areas.

But in both non-urban and urban counties, the increases were significant, at P=0.007 and P<0.001, respectively.

Among patients with an identified HCV risk factor, 73.1% reported using injection drugs, with similar proportions in both non-urban and urban regions.

At the same time, the pattern of drug treatment admissions for those 12 through 29 was changing in the four states, the investigators reported, with a 21.1% increase over the 7-year period in the proportion reporting any opioid use.

The proportion of admissions related to any-opioid injection also rose 12.6%, while the proportion of patients reporting non-opioid injection increased by 2.1% (P<0.05 for both).

Taken together, the investigators argued, the data suggest "the increase in acute HCV infections in central Appalachia is highly correlated with the region's epidemic of prescription opioid abuse."

The HCV increases are also "facilitated" by the increasing number of people using injection drugs, the researchers argued.

Although the rate of HIV in the region has not risen markedly, the HCV increase "raises concerns" about the potential for a greater number of HIV cases, the investigators concluded.

Indeed, injection drug use appears to have fueled an HIV outbreak in Indiana, where about 140 cases have been reported, some 80% of them linked to injection drugs.

In that outbreak, 75% of patients were co-infected with HCV.

The investigators of the four-state HCV increase cautioned, however, that the study is ecologic in nature and can't demonstrate a causal relationship between rising HCV infections and increasing injection drug use.

They also cautioned that the data is likely to underestimate acute HCV infections -- some people might have asymptomatic disease and not seek medical attention while others, such as the homeless, might not be able to seek attention even if they were ill.

The treatment admission data is also likely an underestimate because reporting requirements vary from state to state.

The analysis was supported by the CDC. Authors are employees of the agency or the health departments of Kentucky, Tennessee, Virginia, or West Virginia.

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